East Kent Maternity Services: Independent Investigation

Statement

The following Statement was made in the House of Commons on Thursday 20 October.

“With permission, Mr Speaker, I will make a Statement on the review into East Kent maternity services.

Few things could be as tragic as the death of a child, yet knowing that that death was ‘wholly avoidable’ comes with its own unimaginable pain. It is thanks to the tireless efforts, courage and determination of families in East Kent that we have been able to shine a light on maternity failings in East Kent Hospitals University Trust. Dr Bill Kirkup’s report, published yesterday, contains some stark and upsetting findings. From examining over 200 births in that trust between 2009 and 2020, he found that, had care been given at nationally recognised standards, 45 babies might not have lost their lives, and many more families might not have experienced such distress at what should have been their time of joy. He also found a toxic culture within the trust, with a

‘disturbing lack of kindness and compassion’

and victims’ families even blamed for their devastating losses. Before I say more, Mr Speaker, I want to say this: I am profoundly sorry to all the families affected. This should never have happened, and we will work tirelessly to put it right.

With the report having been published just yesterday, I am sure honourable Members will understand our need to carefully consider all of its details. I will be reviewing all the recommendations, and will issue a full response once I have had time to consider them. However, given the gravity of what the report reveals, I felt it was important to come to the House today and update colleagues on the steps we are already taking to improve maternity services in East Kent and across the country.

The report itself is a litany of failure that makes for very difficult reading. It details failures of team working, failures of professionalism, failures of compassion, failures to listen, failures after safety incidents and ultimately a failure of leadership. The review heard about women and family members feeling patronised, ignored or told off, with one woman hearing from a doctor:

‘Some parents just aren’t supposed to have children.’

Some people felt they were unimportant, or too much trouble. One woman was reportedly told by a staff member that they were sorry for her loss, but that her baby was dead, and that there were other babies who were still living who needed attending to. These kinds of failures showed up at every level of patient care, with no discernible improvement over the whole timeframe of the review. The trust failed to read the signals and missed every opportunity to put things right.

These are difficult things to hear, and especially hard because I know that so many of us have experienced for ourselves the brilliant care that NHS maternity services can offer. We must take nothing away from the hundreds of thousands of incredible people working day and night in maternity services across the country, yet we cannot pretend that the story of East Kent is a one-off. Reviews from Morecambe Bay and Shrewsbury and Telford paint a more disturbing picture. While they may be some of the most extreme examples—and we must hope that they are—they are certainly not isolated incidents. Colleagues will know that, just last month, Donna Ockenden began her independent review into maternity services at Nottingham University Hospitals NHS Trust.

We entrust the NHS with our care when we are at our most vulnerable. Everyone has the right to expect the same high-quality care, no matter who they are or where they live. We are already taking a number of steps to improve the quality of maternity care in East Kent and across the country. An intensive programme of maternity support was put in place at East Kent Hospitals University NHS Foundation Trust in September 2019, overseen by NHS England, the Kent and Medway integrated care system and the trust’s board. The trust has been allocated a maternity improvement adviser and an obstetric improvement adviser. We will also continue to ensure the highest standards at national level.

I am grateful to Dr Kirkup for the extensive recommendations in his report, but it is vital that they are not viewed in isolation. As Dr Kirkup said, since his Morecambe Bay investigation in 2015,

‘maternity services have been the subject of more significant policy initiatives than any other service’,

so his recommendations must be considered alongside existing work to improve maternity outcomes.

First, there is our independent working group. The group is one of the key immediate and essential actions from the Ockenden review and has begun its important work. The group, chaired by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists, is advising the maternity transformation programme in England on how it can take forward the findings of both the Ockenden and the Kirkup reports. Next, our new maternity quality surveillance framework is a vital tool for proactively identifying problems in trusts, so that they can get support before serious issues arise. In March 2022, NHS England announced a £127 million funding boost for maternity services across England, to help ensure safer and more personalised care for women and their babies. Even with that essential work, we recognise that there is still a long way to go and much more work to be done to put things right.

In closing, I want to thank Dr Kirkup and his team. His experience has been invaluable, and I know that his approach of putting families first has been welcomed. I also know that hearing the accounts of families has been a harrowing experience at times, yet, as he said, it is difficult to imagine just how much harder it was for the families as they relived some of their darkest days. I am sure the whole House will join me in paying tribute to those families, whose tireless determination to find the truth and tell their stories has brought us to this important point. Nothing we do can bring back the children they have lost or fill the tragic void of a life never lived, but now we know their stories, we will listen, learn and act, so that no other family should ever experience such pain. I commend this statement to the House.”

My Lords, I start by thanking Dr Bill Kirkup and his team for bringing together a report of harrowing events. This litany of failures makes for very difficult reading, and it marks another landmark for a further group of families fighting for justice who should not have had to do so. Forty-five babies could have survived had they received care at the nationally recognised standards. I am sure that the thoughts of the whole House are with the bereaved families at this extremely painful time.

This is, regrettably, yet another example of women’s voices being ignored and silenced, to the extent that some were told that they were to blame for the deaths of their babies. At a time when women are at their most vulnerable, they were let down by the very people who they were relying on to keep them safe. However, this is not a one-off: East Kent is the latest in a long line of maternity scandals, including at Shrewsbury and Telford Hospital NHS Trust and Morecambe Bay, while the upcoming review of services in Nottingham is expected to be highly critical. Dr Kirkup said that avoidable deaths happened because recommendations that had been made following reports into other scandals had not been implemented. I would be grateful if the Minister could respond to this.

We know that no woman should ever have to face going into hospital to give birth, not knowing whether she and her baby will come out alive. Those who allowed this culture of neglect and what was referred to in the report as a disturbing

“lack of kindness and compassion”

to take root must be held accountable. Can the Minister tell your Lordships’ House how this may happen?

It is shocking that there is a pattern of avoidable harm in maternity units across the country. Half the maternity units in England are failing to meet safety standards. Pregnant women were turned away from maternity wards more than 400 times last year. One in four women are unable to get the help that they need when in labour. The Government need to fully accept all the recommendations in Dr Kirkup’s review without delay. I hope the Minister will today confirm that this is the case.

My Lords, I want to start from these Benches by sending my deepest sympathies to the bereaved families and to say that we admire the parents for their campaigns over many years against the dreadful treatment by the east Kent hospitals trust for more than a decade. I echo the thanks and gratitude from the noble Baroness, Lady Merron, to Dr Kirkup and his team. Once again, he has risen to the challenge of providing a very clear picture of what has gone wrong at a hospital trust.

The trust failed to read the signals over an 11-year period. The Kirkup report puts this very bluntly and is exceptional in the way it uses evidence. Yes, there is the evidence of the voices of mothers and their families and the evidence from staff, but equally important is the use of data, especially the CESDI data from the Confidential Enquiry into Stillbirths and Deaths in Infancy. In the section headed “What happened to women and babies”, paragraph 1.16 says that

“we have not found that a single clinical shortcoming explains the outcomes. Nor should the pattern of repeated poor outcomes be attributed to individual clinical error, although clearly a failure to learn in the aftermath of obvious safety incidents has contributed to this repetition.”

This short paragraph encapsulates how failings have become cultural in the trust. Paragraph 1.19 says that

“we have found that the origins of the harm we have identified and set out in this Report lie in failures of teamworking, professionalism, compassion and listening.”

It is really worrying to have the report from the CQC of a few days ago, which echoed these exact points but more broadly across maternity services in England.

As has been mentioned, there is a wider problem. We know that. The reports on Morecambe Bay, Shrewsbury, Telford and now Nottingham, where Ms Ockenden is now working, show that systemic and cultural failures, especially with the complexity of regulators, are creating real problems. There is the idea that clinical staff will allow favouritism and the opposite of growing and supporting staff, while letting things fester and not caring to drag patients into their concerns.